Breast Cancer Treatments & Surgery
Bedside ultrasound is used as an adjunct to clinical breast examination. A targeted ultrasound examination of the region of interest in the breast may reveal more information about the underlying breast tissue than clinical examination alone. Bedside ultrasound does not replace formal diagnostic breast ultrasound which is performed by highly trained breast sonographers and interpreted by specialist radiologists with an interest in breast pathology. Bedside ultrasound is used to target fine needle and core biopsies performed in rooms.
Fine Needle Biopsy
Fine needle biopsies are performed in rooms either of palpable breast lumps or under ultrasound guidance of impalpable lesions. A local anaesthetic is not usually needed but may be required for some patients. Small samples of breast tissue are obtained for cytological examination by specialist pathologists, to obtain information about the breast tissue. Fine needle biopsy is used to complete the "Triple Test", the gold standard in breast assessment. A result is available after 24 hours.
Core biopsies are performed in rooms under local anaesthetic. A small sample of the breast lesion is removed in the core sample for examination by specialist pathologists. Some minor bruising and swelling may follow a core biopsy, as it is a minor surgical procedure. Core biopsies are obtained of breast lesions in order to make a definitive histological diagnosis so that definitive management can be planned. A result is available after 48 hours.
Aspiration of Cyst
Most simple breast cysts do not need to be aspirated. Complicated simple cysts may be aspirated to relieve symptoms. Complex cysts are aspirated in order to obtain material for examination by specialist cytopathologists to exclude breast cancer. Palpable cysts are aspirated simply without an ultrasound, but impalpable complex cysts are aspirated with fine needles using bedside ultrasound for accurate targeting. A local anaesthetic may be used if necessary. Results are available after 24 hours.
Operating Theatre Procedures
Breast Conservation Surgery
A total mastectomy is no longer always needed for breast cancer treatment. All patients with benign disease and the majority of women with breast cancer can be treated safely with breast conservation surgery. A range of surgical approaches are used to maximize the cosmetic result after breast-conserving procedures. Radiotherapy is usually used to reduce the risk of recurrence in the remaining breast tissue after breast-conserving surgery. Occasionally a second surgical procedure is necessary if breast conservation is not successful in removing all of the affected breast tissue.
A mastectomy is sometimes the best procedure to manage certain conditions. Breast reconstruction may be performed either simultaneously or delayed, as the clinical situation requires. Women are encouraged to actively participate in planning the individual procedure that best suits their particular situation. All the breast tissue, and usually the nipple, is removed by mastectomy. Skin preserving (subcutaneous) procedures are used to maximize the cosmetic result if breast reconstruction is planned, and in some cases, the nipple and normal breast skin can be preserved and only the diseased tissue removed from beneath the skin, with an immediate breast reconstruction achieved with a variety of methods. The breast care nurses are actively involved in the psychological support of all patients undergoing breast cancer surgery in our hospitals.
Surgically removing all of the lymph nodes situated in the axilla (armpit) is sometimes a necessary part of breast cancer surgery if the breast cancer cells have spread to these nodes. Axillary clearance is often performed if the sentinel node has been found to contain cancer. On average 20 - 30 nodes are removed, but this does not have an adverse effect on the immune system. Some (approximately 15%) patients develop arm swelling (lymphoedema) which is well managed by lymphatic drainage massage and a compression sleeve.
Sentinel Node Biopsy
The sentinel lymph node is the first node breast cancer cells will reach if they spread beyond the breast. Identifying and testing the sentinel node is therefore very helpful for planning subsequent breast cancer treatment after surgery.
Radioactive and blue dye is used to map the location of the node before surgery, and the gamma probe is used during the operation to find the sentinel node. The sentinel node is then removed and sent to pathology for detailed microscopic examination.
Patients without cancer cells in their sentinel nodes may be safely spared the more extensive procedure of full clearance of all their axillary nodes.
A Microdochectomy is a targeted surgical procedure, whereby a single duct behind the nipple is removed for examination by the breast pathologist.
The Microdochectomy is performed if there is a suspicious discharge from a single duct in the nipple. The specific duct is identified under general anaesthetic and is isolated with a fine probe so that it can be removed without damaging the remaining ducts.
A Microdochectomy is most suitable for younger women who wish to preserve the ability to breastfeed after surgery. A small incision around the areola is used to minimise scarring after surgery.
Subareolar Duct Excision
The major breast ducts coalesce behind the nipple/areola complex. Suspicious discharge for the nipple may be the first indication of significant disease in the ducts, even in the absence of clinical or imaging findings. Subareolar duct excision removes all of the major ducts from behind the nipple, to stop the discharge, and to provide the pathologist with the duct tissue for examination. The nipple is preserved, but breastfeeding is not possible after a sub-areola duct excision. Usually, the cause of the discharge is benign duct disease requiring no further treatment, but if breast cancer is found in the ducts then further surgery may be required.
Early breast disease is often detected on mammogram or ultrasound before a lump can be felt in the breast. Surgical excision of that part of the breast may be needed in order to obtain tissue for examination by the pathologist, or for definitive treatment. As the lesion in the breast is not palpable, a fine hook wire is inserted into the lesion on the day of surgery using the mammogram or ultrasound to guide accurate placement of the wire.
The surgeon can then use the guidewire during the operation to accurately remove only the abnormal breast tissue and preserve normal tissue.
This complex procedure improves both the accuracy of excising the abnormality and breast cosmesis by preserving normal tissue.
Radio Localisation (ROLL)
Similar to a hookwire procedure, this technique is used to guide the surgeon when removal of a piece of tissue is necessary where there is no lump.
A tiny dose of radioactive tracer (the same that is used for sentinel node procedures) is injected under ultrasound guidance to the area of tissue that requires removal. This is performed before the operation, either the day before or the day of surgery. During the operation the surgeon uses a gamma probe to detect the tiny area of radioactivity (similar to how a metal detector works). The area of tissue is then removed.
This procedure improves both the accuracy of excising the abnormality and breast cosmesis by preserving normal tissue, and can avoid the use of a wire.
Open surgical biopsy under anaesthetic has largely been replaced by fine needle and core biopsies (see above). There remains however the unusual situation where a lesion in the breast is atypical and needs to be fully removed for complete examination by the pathologist.
Occasionally a patient may prefer to have a benign lesion removed rather than continuing in surveillance. Cosmetic skin crease incisions are used to reduce the risk of scarring. Buried dissolving sutures and waterproof dressings are used so that the patients can return to normal activities as soon as possible.